COS programming wrapped up Sunday in Austin, with the conclusion of the ophthalmology, optometry, and YES programs.

Surgical management of glaucoma

Sunday morning programming began with presentations on the surgical management of glaucoma, covering device-based canal surgery, incisional-based canal surgery, subconjunctival procedures, and laser-based surgery. Nathan Radcliffe, MD, New York, focused his talk on the HORIZON and COMPARE trials, which looked at Hydrus (Ivantis) plus phaco vs. phaco alone and Hydrus vs. two iStents (Glaukos), respectively. In the HORIZON trial, efficacy got better from year 1 to year 2 in the Hydrus group, compared to phaco alone, and 78% of those in the Hydrus group were medication free at 2 years. Dr. Radcliffe also noted that the Hydrus group was less likely to go on to have incisional glaucoma surgery vs. the phaco-alone group. The COMPARE study compared off-label, standalone Hydrus to two iStent implants. The Hydrus group was more likely to reduce or eliminate medication burden and achieve a 20% reduction in IOP. There were also fewer further surgical interventions for glaucoma in the Hydrus group, Dr. Radcliffe said. “This study is really what we’ve been asking for, which is good comparative data,” Dr. Radcliffe said. Manjool Shah, MD, Ann Arbor, Michigan, tackled the topic of subconjunctival procedures, saying that trabs and tubes are still relevant, but there are new device-based procedures entering this space. Currently, the XEN Gel Stent (Allergan) is the only FDA approved one. Subconjunctival devices, like XEN, can require postop management because, as Dr. Shah put it, these devices are non-physiologic, leading the body to want to scar and at times necessitating needling.

Editors’ note: Drs. Radcliffe and Shah have financial interests with various ophthalmic companies.

'Feeling the Burn'

Friction from little to no flow around the phaco needle due to occluded tip, a tight wound, or OVD and use of continuous power vs. pulsed can lead to a quick, unexpected wound burn. Sumit “Sam” Garg, MD, Irvine, California, showed a couple of case examples where wound burn occurred and how he managed these situations. In one video case, Elizabeth Yeu, MD, Norfolk, Virginia, noted a plume that occurred. When this happens, she said, you should stop immediately as this indicates there is not enough fluid exchange occurring. After a burn occurs, Dr. Garg said you need to close the wound with sutures. He’s a fan of mattress sutures, but in the case video he showed, these didn’t close well, necessitating glue and more sutures. Postoperatively, the sutures should be left in for a long time, he said. In a separate case that was referred, Dr. Garg showed how he repaired a wound burn that had taken place a while ago. He used a derm punch to make a 3 mm partial punch, removed the tissue that was unhealthy, and made a patch graft with the cornea. When putting stitches in, Dr. Garg noted the importance of making stiches a little shorter as they near the visual axis. Dr. Garg’s main takeaways for corneal wound burn management is to 1) recognize occurrence early; 2) consider a new wound to complete the case; 3) consider induced cylinder; and 4) be patient.

Editors’ note: Dr. Garg does not have financial interests related to his comments.

Management of the phakic loose lens

A video session Sunday morning featured a variety of case presentations and discussion. Nicole Fram, MD, Los Angeles, offered several pearls and pitfalls relating to scleral fixation. She finds that the number one reason for scleral fixation is lasso repositioning. Dr. Fram said it’s important to understand if you can approach anteriorly, and she suggested examining the patient in the upright and supine positions. She also added that it’s important to understand how to manage Soemmering’s ring and cautioned against fixating an IOL with a large Soemmering’s ring. Also during the session, Bac Nguyen, MD, Houston, shared some tips for reloading a trabecular micro-bypass stent, particularly iStent inject (Glaukos) and Hydrus. For iStent inject, Dr. Nguyen recommended using a surface for counter-traction, rotating the injector to visualize the trocar, and positioning the iStent inject so the central inlet of the flange is in line with the trocar. He added that the trocar is very flexible, and if you angle slightly downward, it could allow for an easier upward motion for reloading. If all else fails when trying to reload, he said to remove the iStent inject using intraocular forceps and reload outside of the eye. With Hydrus, Dr. Nguyen said, typically, the device is at least partially implanted, not free floating in the anterior chamber. He said to scroll the injector wheel forward until the inner lock is open, place the injector adjacent to the proximal end of the Hydrus with the cannula behind the device, and the open inner lock in front of it. Line up the inner lock with the Hydrus inlet, he said, and scroll the injector wheel backwards until the device is completely retracted into the injector. If you need to reposition Hydrus, Dr. Nguyen recommended using a Sinskey hook. Wrapping up the session, Douglas Koch, MD, Houston, discussed a patient with a subluxated capsule/prosthesis with an open posterior capsule. The patient, he said, had an iris prosthesis that had been stable for about 5 years. The patient then developed glaucoma and “the whole bag and iris are loose and flopping around,” he said. Since the patient had an open posterior capsule, Dr. Koch said he needed to figure out how to stabilize the iris prosthesis and the IOL in the bag. He ended up suturing through the prosthesis since he essentially was dealing with a “dead bag” with no cortex to speak of.

Steve Charles, MD, Memphis, Tennessee, and Keith Warren, MD, Overland Park, Kansas, provided slew of retina considerations for anterior segment surgeons in a Saturday afternoon session. Dr. Charles emphasized several points in his presentation, starting with the importance of performing a careful peripheral fundus exam prior to LASIK/PRK, refractive cataract surgery, and refractive lens exchange. Flap tears and holes must be repaired with laser retinopexy, Dr. Charles said. When it comes to diabetic macular edema, Dr. Charles said evidence suggesting an increase in DME after cataract surgery is flawed. What’s more, he said there is no reason for DME to stabilize or dry up prior to cataract surgery. The anti-VEGF injection cycle, however, should not be altered, and cataract surgery should be timed for midway between injections. Similar to DME, Dr. Charles said there is no need to stabilize wet AMD before cataract surgery, and the anti-VEGF cycle should remain the same with cataract surgery between injections. Evidence that suggested cataract surgery could make AMD worse has been disproven, Dr. Charles said. In patients with drusen who require phaco, Dr. Charles cautioned against multifocal IOLs in patients between 50–60 years old due to likelihood of disease progression to geographic atrophy and/or neovascular AMD and the IOL’s nature to decrease contrast sensitivity. If macular surgery is needed and the patient has a cataract, Dr. Charles advised against a combined procedure. If it is 1–2+ nuclear sclerosis, pars plana vitrectomy and ILM peeling should be performed before cataract surgery. If the cataract is 3+ or greater, phaco should be performed first. The axial length from the RPE should be measured using low-coherence interferometry, not A-scan biometry, and pars plana vitrectomy should be performed one month after surgery. Finally, Dr. Charles advised taking OCT on every cataract surgery patient to avoid visual surprises. “There is a tremendous amount of invisible pathology” that can be identified when looking at all gray-scale OCT B-scan slices, he said. Indications for anterior segment surgeons to perform vitrectomy include capsule rupture during phaco, vitreous prolapse, pediatric or traumatic cataract, and posterior vitreous pressure, Dr. Warren said. The first step is to visualize the clear, gel-like material, Dr. Warren said. This can be done with retroillumination and adjuvants such as triamcinolone. Vitreous needs to be cut away from the wound, pulling it away from the anterior chamber and a lens should be put in at the time of that operation, if possible, Dr. Warren said. He explained that small gauge cutters are excellent for anterior segment surgeons because the wounds they create are sutureless and self-sealing; there is less morbidity and reduced recovery and surgery time; and they can facilitate an anterior or pars plana approach. A faster cut speed takes out smaller snippets, which is what you want when handling vitreous as it results in the least amount of traction. For anterior segment surgeons, Dr. Warren recommends a small gauge cutter, a 300–600 mm Hg vacuum, and a cut rate between 900–1,200 cuts per minute. Important do’s listed by Dr. Warren include: clean vitreous thoroughly from the anterior chamber; remove easily accessible lens fragments; use viscoelastic to posteriorly displace vitreous; check the angle and sulcus for retained fragments; place a non-silicone lens in the ciliary sulcus; and treat inflammation aggressively. Important don’ts Dr. Warren emphasized include: don’t cut what you can’t see; don’t withdraw the cutter without cutting engaged; don’t follow lens fragments into the posterior segment; don’t cut nucleus fragments with the cutter; don’t hydrate excessively; and don’t try to be a hero.

Editors’ note: Dr. Charles has financial interests with Alcon. Dr. Warren does not have financial interests related to his comments.

EyeWorld Onsite is a digital publication of the American Society of Cataract and Refractive Surgery and the American Society of Ophthalmic Administrators.